Provider Demographics
NPI:1194135657
Name:JACK FORD MD PC
Entity type:Organization
Organization Name:JACK FORD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-475-1810
Mailing Address - Street 1:3505 AUSTIN BLUFFS PKWY STE 306
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5755
Mailing Address - Country:US
Mailing Address - Phone:719-475-1810
Mailing Address - Fax:719-475-1812
Practice Address - Street 1:3505 AUSTIN BLUFFS PKWY STE 306
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5755
Practice Address - Country:US
Practice Address - Phone:719-475-1810
Practice Address - Fax:719-475-1812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR00016135207VG0400X
CODR00053716208D00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty